1. De-prescribing in Older Adults
Wael Hamade, MD, FAAFP
04/08/2016

2. DISCLOSURES None of the faculty, planners, speakers, providers nor CME committee has any relevant financial relationships with commercial interest There is no commercial support for this CME activity

3. Objectives
Understand the prevalence of inappropriate medications use in the elderly
Understand the effects of age on pharmacokinetics and pharmacodynamics
Use evidence- based criteria (BEERS, STOPP, START) to evaluate for potentially adverse drug events in the elderly
List potentially inappropriate medication classes in the elderly
Develop a systematic approach to managing elderly patients with multiple medications, including principles of prescribing for older patients

4. Aging of the US Population
2000
2030
Topic
Slide 4

5. Elderly People Elderly use 3X more medications than younger patients
Increased prevalence of ADE’s leading to an  in drug related morbidity and mortality
Unique medication needs of older people
Elderly are not well represented in clinical trials
Less is more
Need to balance risk and benefit

6. Elderly Population and Medication 1/2
Seniors represent around 13% of the population, but consume 40% of prescription drugs
By 2040, will be 25% of population, will buy 50% of prescription drug
90% of community-dwelling seniors take at least one prescription medication
>20% of ambulatory older adults receive at least one potentially inappropriate medication

7. Elderly Population and Medications 2/2
15% to 25% of drug use in seniors is considered inappropriate or unnecessary
ADE’s occur in 35% of community-dwelling older adults
ADE’s are responsible for up to 28% of acute geriatric hospital admissions
In nursing homes, $1.33 is spent on ADEs for every $1.00 spent on medications

8. Don’t Forget OTC Meds Elderly Purchase 40% of OTCs
Use of OTCs is 3-fold higher in elderly
Nearly 15 billion spent each year on herbal products total
Elderly use twice as much herbals

9. Why Geriatric Pharmacotherapy is Challenging
More drugs are available each year
FDA and off-label indications are expanding
Formularies change frequently
Drugs change from prescription to OTC
Age-related changes, Pharmacokinetics & Pharmacodynamics
Functional and Environmental Changes

10. Pharmacokinetics
Absorption
Distribution
Metabolism
Elimination
Topic

11. Absorption Route of administration What is taken with the drug
Reduced intestinal blood flow
Decreased rate of gastric emptying
Alterations in gastric acidity

12. Distribution Decreased body water Increase adipose tissue
Deceased lean body mass
Decrease serum albumin -> increase amount of free drug -> drug toxicity

13. Metabolism
Metabolic clearance of drugs by the liver may be reduced due to:
decreased hepatic blood flow
decreased liver size and mass
Breakdown of drugs metabolized by Phase I pathways is reduced with aging

14. Elimination (Ideal weight in kg) (140 – age) Effect of aging:
_________________________ x (0.85 if female)
(72) (serum creatinine in mg/dL)
Effect of aging:
–   renal blood flow
–   renal size
–   GFR and tubular secretory function
Reduced elimination  drug toxicity
Serum creatinine doesn’t reflect cr clearence
Cockcroft-Gault Equation for estimating cr cl

15. Pharmacodynamics Age-related changes:
 sensitivity to sedation and psychomotor impairment with benzodiazepines
 level and duration of pain relief with morphine
 drowsiness with alcohol
 HR response to beta-blockers
 sensitivity to anti-cholinergic agents

16. Functional and Environmental Changes
Visual impairment
Hearing impairment
 rates of cognitive impairment
Transportation barriers
Complex dosing regimens
Financial constraints
Multiple prescribers

18. Case 1 (1 of 4)
87 yo F comes to the clinic because she has daytime fatigue, dizziness and worsening leg edema
PMH: DM II with neuropathy, osteoporosis (hip fracture 1 year ago), hypertension, frequent falls, and urinary incontinence.
Medication list: glipizide 5 mg q12h, propranolol 40 mg q12h 50 mg daily, pregabalin 300 mg q12h, alendronate 70 mg/week, lisinopril 2.5 mg daily and pioglitazone 15 mg daily
Topic

19. Case 1 (2 of 4)
On examination, weight is 147lb (increased form 130lb over the past 6 months) . BP is 140/75 mmHg
Over the past 3 months, blood pressure has ranged from 140 to 160 mmHg systolic and from 80 to 90 mmHg diastolic, with no orthostatic
A1C 8.0, Estimated cr clearance is 45 mL/min; it has declined over the past 6 months
Topic
Slide 19

20. Case 1 (3 of 4)
Which of the following would address the patient’s most immediate need?
Increase Pioglitazone to 30 mg daily
Reduce pregabalin to 150 mg q12h.
Increase lisinopril to 10 mg daily.
Start furosemide 40 mg daily
Topic

21. Case 1 (4 of 4)
Which of the following would address the patient’s most immediate need?
Increase Pioglitazone to 30 mg daily
Reduce pregabalin to 150 mg q12h.
Increase lisinopril to 10 mg daily.
Start furosemide 40 mg daily
Topic

22. Polypharmacy = Negative Outcomes
Overutilization
Adverse Drug Events
Poor Adherence
Geriatric “Syndromes” – Urinary Incontinence – Cognitive Impairment – Loss of balance leading to falls/fractures

23. Adverse Drug Events Risk is 15% with two medications
Risk increases to 58% with 5 meds
Risk increases to 82% with ≥ 7 meds
Additional medications lead to greater incidence of drug interactions

24. Risk Factors For ADE’s 6 or more concurrent chronic conditions
12 or more doses of drugs/day
9 or more medications
Prior adverse drug event
Low body weight or low BMI
Age 85 or older
Estimated CrCl < 50 mL/min
Topic

25. Drug – Drug Interactions Matter
Drug – drug interactions ↑ with polypharmacy
Age-related changes can lead to exaggerated interaction responses
May contribute to ↑ morbidity and mortality
Clinicians must be aware of relevant risks of commonly prescribed medication combinations

26. Medications Often Overlooked
Aspirin
Warfarin
Insulin and Sulfonylureas
Digoxin
Anticholinergic
Benzodiazepines
Proton Pump Inhibitors (PPIs)
Nonsteroidal Anti-inflammatories (NSAIDs)
Antipsychotics
Bisphosphonates

27. Case 2 (1 of 3) 84 yo Frail F, here first visit to your practice
Recent fall with minor injuries at home.
Her daughter reports her mother was walking back to the living room when she appeared to lose consciousness and fall.
PMH: CHF, DM type 2 with neuropathy, CKI, Insomnia, Osteoporosis ,Hypothyroidism, Osteoarthritis, Urinary Incontinence, GERD and constipation

28. Case 2 (2 of 3) PE : Afebrile HR 85, RR 12, BP 135/70, no orthostatic
Exam unremarkable except skin tears
A1C 7.2
EKG – sinus rhythm

29. Case 2 (3 of 3) Med List: Which medications Attract your attention?
ASA 81 mg daily
Oxybutynin ER 10 mg po once daily
Omeprazole 40 mg po BID
Gabapentin 300 mg po QID
Diphenhydramine 25 mg QHS
Iron 325 mg TID
Levothyroxine 300 mcg daily
Senna 2 tab po daily
PEG 3350 Oral powder
Meclizine 25 mg po once daily
Digoxin 0.25 mg po daily
Potassium Cl 20 mEq po once daily
Glyburide 10 mg po BID
Furosemide 40 mg po once daily
Spironolactone 50 mg po once daily
Risk Factors:  # of meds  # of conditions  Age  Creatinine clearance
 BMI

30. Overtreatment of diabetes in older adults
Potential overtreatment of diabetes mellitus in older adults with tight glycemic control.
Jama Internal Medicine.2015;175:
Overtreatment of diabetes in older adults

31. Potential Overtreatment of Diabetes
In 2014 there were more hospital admissions related to hypoglycemia than hyperglycemia.
25% of all ER/hospitalizations for ADE’s
Undesirable health outcomes:
3x risk of death/5 years
More CV events
Increased falls

32. Prescribing Cascade Drug 1 Drug 2 Drug 3
ADE interpreted as new medical condition
Drug 2
ADE interpreted as new medical condition
Drug 3

34. Case 3 (1 of 4)
78 yo M who presents for an urgent visit due to hypoglycemia.
His diabetes has been well controlled ( for past 2 yrs) on glipizide 5 mg daily, but he had a low sugar of 35 yesterday afternoon and last night.
He was seen by your colleague 2 days ago with complaints of productive cough and worsening SOB.
He was diagnosed with COPD exacerbation. He was prescribed SMX-TMP and prednisone burst and taper.
PMH: DM II, HTN, COPD and chronic low back pain

35. Case 3 (2 of 4)
Medication list: ASA 81 mg daily, losartan 50 mg daily, glipizide 5 mg daily, atorvastatin 40 mg daily, ibuprofen 400 mg q8h PRN, mg daily, tiotropium cap inhaled daily, albuterol PRN and SMX-TMP DS 1 tab twice a day for 7 days
He reports he did not fill the prednisone because it made him jittery and caused poor sleep in the past.
PE: Afebrile, HR 80, RR 12, BP 150/90, O2 sat 94% on room air. expiratory wheeze, otherwise unremarkable exam
Labs: A1c 1 month ago 8.2

36. Case 3 (3 of 4) What is the most likely cause of his hypoglycemia?
Unintentional overdose of glipizide
Interaction between tiotropium and glipizide
Interaction between SMX-TMP and losartan
Interaction between SMX-TMP and glipizide

37. Case 3 (4 of 4) What is the most likely cause of his hypoglycemia?
Unintentional overdose of glipizide
Interaction between tiotropium and glipizide
Interaction between SMX-TMP and losartan
Interaction between SMX-TMP and glipizide

38. Hypoglycemia after antimicrobial drug prescription for older patients using sulfonylureas.
JAMA Internal Medicine 2014;174:

39. Hypoglycemia after antimicrobial drug prescription

40. Hypoglycemia after antimicrobial drug prescription
NNH Clarithromycin = 71
These 5 responsible for 13% of all hypoglycemic episodes
28% of sulfonylurea users were prescribed one of these Antibiotics

41. Potassium-Increasing Drug-Drug Interactions
BMJ 2014;349:g6196

42. Drug-Drug Interaction Lessons
Watch carefully for hyperkalemia interactions with trimethoprim-sulfamethoxazole in high risk patients
Advancing age, diabetes, # of K+ ↑drugs, and renal impairment will increase risk
Use lowest possible dose, shortest duration, monitor
When clinically appropriate, alternative antibiotics should be considered

43. Case 4 (1 of 4)
69 yo M with newly diagnosed Alzheimer’s brought to your office because he has been seeing his dead wife for the past 2 months
History includes agitation and insomnia. Patient’s son is requesting a Rx for antipsychotic
PMH: Dementia, HTN, CHF, depression, insomnia and HTN

44. Case 4 (2 of 4)
PE: BP 145/90 mmHg. There are no tremors or other neurologic abnormalities.
MOCA score 15 of 30
Laboratory findings are normal.
CT of the head shows mild cortical atrophy.

45. Case 4 (3 of 3) Med List: Paroxetine 20 mg at bedtime
Atenolol 25 mg q12h
Meclizine 25 mg daily
Amitriptyline 25 mg at bedtime
Digoxin mcg daily
Which Meds has the highest anticholinergic burden?

46. Antichlinergic Burden Scale ACB
Boustani MA et al. Impact of Anticholinergics on the Aging Brain. Aging Health (3):

47. Anticholinergic and Cognition
JAMA Intern Med 2015;173(3); 401-7

48. Antipsychotic adverse outcomes
Ann Intern Med 2014;161:242-8

49. Antipschotic adverse outcome
JAMA Intern Med 2015;175(3):450-2.

51. = ? ✚ Increased susceptibility to: Age-Associated changes Polypharmacy
= ? ✚
Increased susceptibility to:
Polypharmacy
Drug interactions
Adverse drug events
Prescribing cascade
Nonadhenrence
Potentially inappropriate prescribing
Age-Associated changes
Pharmacokinetics
Pharmacodynamics
Increase in co- morbidities

52. What tools are available?

53. What tools are available?
BEERS criteria
STOPP / START
Medication Appropriateness Index
ARMOR Tool
American Geriatrics Society 2015 Beers Criteria Update Expert Panel Updated Beers Criteria for
Potentially Inappropriate Medications Use in Older Adult. J Am Geriatric Soc Nov–VOL. 63, NO. 11
O’Mahony D, O’Sullivan D, Byrne S, O’Connor MN, etc P.STOO/START criteria for potentially
inappropriate prescribing in older people: version 2.Age Ageing.2015 Mar;44(2):2138.

54. BEERS CRITERIA Updated in 2015 by the American Geriatrics Society
Intend to improve drug selection and reduce exposure to potentially inappropriate medications in older adults
Beers Goals:
Improve care by decreasing use of potentially inappropriate medications (PIMS)
Educational tool
Quality measure
Research tool
Topic

55. available at GeriatricsCareOnline.org
Beers Criteria 2015 Update
Table 1 : Quality and strength of evidence
Table 2 : Potentially inappropriate medications
Table 3 : Drug/disease state interactions
Table 4 : Drugs to use with caution
Table 5 : Drug/drug interactions
Table 6 : Renal dosing
Table 7 : Drugs with strong anticholinergic properties

56. Table 2 : Potentially Inappropriate Meds
Avoid Amiodarone as first-line therapy for A. Fib unless the patient has CHF or substantial LV hypertrophy
Avoid Digoxin as first-line therapy for A Fib, also as first- line therapy for heart failure. avoid dosages >0.125 mg/d
Avoid Nitrofurantoin in individuals with cr cl <30 mL/min or for long-term suppression of bacteria
Avoid PPI for >8 weeks duration unless for high‐risk patients (eg, chronic NSAID use), erosive or Barrett’s esophagitis

57. Table 3 : Drug-Disease state interactions
Specific Condition
Exacerbating medications to avoid
CHF
NSAIDs, COX-2 inhibitors, Nondihydropyridine CCBs (diltiazem, verapamil) and Thiazolidinediones (pioglitazone, rosiglitazone)
Syncope
Acetylcholinesterase inhibitors (AChEIs), Peripheral alpha-1 blockers, Tertiary TCAs and Antipsychotics
Dementia
Anticholinergics, Benzodiazepines H2-receptor antagonists, Z-Drugs (Eszopiclone, Zolpidem, Zaleplon) and Antipsychotics,
Delirium
Anticholinergics, Antipsychotics, Benzodiazepines, Corticosteroids, H2-receptor antagonists, Meperidine and hypnotics
Seizures
Bupropion Chlorpromazine Clozapine, Olanzapine, Tramadol
ho Falls or Fractures
Anticonvulsants, Antipsychotics, Benzodiazepines, Z-Drugs, TCAs SSRIs and Opioids
Parkinson disease
All antipsychotics (except aripiprazole, quetiapine, clozapine)
Antiemetics ( Metoclopramide ,Prochlorperazine, Promethazine)

58. Table 5: Drug-Drug Interactions

59. Table 5: Drug-Drug Interactions

60. Table 6: Renal Dosing

61. Table 6: Renal Dosing

62. STOPP Criteria
Screening Tool of Older persons Potentially inappropriate Prescriptions
Arranged by physiological system
Highlight drug class duplication, drug-drug interactions, and drug-disease interactions
Gallagher P, Ryan C, Byrne S, Kennedy J, O'Mahony D: STOPP (Screening Tool of Older Persons' Prescriptions)
and START (Screening Tool to Alert Doctors to Right Treatment): Consensus Validation.Int J Clin Pharmacol Ther 2008, 46(2):72-83.

63. STOPP Criteria Examples A. Cardiovascular System
Digoxin at a long-term dose > 125µg/day with impaired renal function (increased risk of toxicity).
Loop diuretic as first-line monotherapy for hypertension (safer, more effective alternatives available).
Thiazide diuretic with a history of gout (may exacerbate gout).
Non-cardioselective beta-blocker with COPD (risk of bronchospasm).
Use of diltiazem or verapamil with NYHA Class III or IV heart failure (may worsen heart failure).
Calcium channel blockers with chronic constipation (may exacerbate constipation).

64. STOPP Criteria Examples B. CNS & Psychotropic Drugs.
TCAs with dementia, narrow angle glaucoma, cardiac conduction abnormalities, or prior history of urinary retention (risk of worsening these conditions).
Initiation of TCAs as first-line antidepressant treatment (higher risk of adverse drug reactions with TCAs than with SSRIs or SNRIs).
SSRI’s with current or recent significant hyponatraemia i.e. Na+ < 130 mmol/l (risk of exacerbating or precipitating hyponatraemia).
Benzodiazepines for ≥ 4 weeks (no indication for longer treatment; risk of prolonged sedation, confusion, impaired balance, falls, road traffic accidents; all benzodiazepines should be withdrawn gradually if taken for more than 4 weeks as there is a risk of causing a benzodiazepine withdrawal syndrome if stopped abruptly).
Antipsychotics (i.e. other than quetiapine or clozapine) in those with parkinsonism or Lewy Body Disease (risk of severe extra-pyramidal symptoms)

65. START Criteria Screening Tool to Alert doctors to the Right Treatment
Highlight under-prescription or omission of clinically indicated, evidence-based medicine
Arranged according to physiological system
Barry PJ, Gallagher P, Ryan C, O'Mahony D: START (Screening Tool to Alert doctors to the Right Treatment)
an evidence-based screening tool to detect prescribing omissions in elderly patients. Age Ageing 2007, 36:

66. START Criteria Examples A. Cardiovascular Syst.
Vitamin K antagonists or direct thrombin inhibitors or factor Xa inhibitors in the presence of chronic atrial fibrillation.
Aspirin (75 mg – 160 mg once daily) in the presence of chronic atrial fibrillation, where Vitamin K antagonists or direct thrombin inhibitors or factor Xa inhibitors are contraindicated.
Antiplatelet therapy (aspirin or clopidogrel or prasugrel or ticagrelor) with a documented history of coronary, cerebral or PVD
Beta-blocker with ischaemic heart disease.
Statin therapy with a documented history of coronary, cerebral or peripheral vascular disease, unless the patient’s status is end-of-life or age is > 85 years.
Angiotensin Converting Enzyme (ACE) inhibitor with systolic heart failure and/or documented coronary artery disease.

67. Medication Appropriateness Index
Hanlon, et al. J Clin Epidemiol 1992: 45 (10):

68. A R M O ARMOR Tool Assess Review Minimize Optimize Reassess
-Beers Criteria -Beta blockers, Pain medications
-Antidepressants , Antipsychotics R
Review
-Drug–Drug interactions
-Drug–disease interactions
-Adverse drug reactions M
Minimize
-Number of medications according to functional status rather than evidence-based medicine O
Optimize
-For renal/hepatic clearance, PT/PTT, beta-blockers, anticonvulsants, pain medications, and hypoglycemics; GDR for antidepressants
Reassess
-Functional/ cognitive status -Clinical status and medication compliance
Haque R. ARMOR: A Tool to Evaluate Polypharmacy in Elderly Persons, Annals of Long Term Care, June 2009, Volume 17, Issue 6: p26-30

69. Optimize Prescribing
“Each capsule contains your medication plus a treatment for each of its side effects.”

70. Steps to Optimize Prescribing in the Elderly
Step 1: Brown Bag Biopsy…Reconcile
Step 2: Determine medication
Appropriateness, Match meds to medical conditions
…Prescribing “start low, go slow”
Step 3 : Deprescribing…The clean up
Identify and discontinue inappropriate meds

71. Interdisciplinary Geri Team

72. Brown Bag Biopsy & Medication History
Have patient to bring in all medications at each visit
Get a complete medication history
Is the drug being given correctly? dose, route, frequency
Match problem list with drug list
Is appropriate for the patient?
Are any symptoms/complaints related to drug therapy?

73. Steps Before Prescribing a New Drug 1/2:
Is this medication necessary?
What are the therapeutic end points?
Make certain the drug being prescribed has a clinical indication ?
Do the benefits outweigh the risks?
Understand age-related physiological changes
Interpret the evidence
Topic

74. Steps Before Prescribing a New Drug 2/2:
Could it interact with diseases, other drugs?
Know the side-effect profile of the drugs being prescribed
Be aware of the prescribing cascade !!! Is it used to treat effects of another drug?
Could 1 drug be used to treat 2 conditions?
Consider treatment complexity and feasibility
Nonadherence

75. Principles of Prescribing
Start with a low dose
Titrate upward slowly, as tolerated by the patient
Consider length of therapy, dosing schedule and cost
Look for duplicate therapies or pharmacologic effect
Eliminate unnecessary medications and simplify dosing regimens
Always consider non-pharmacologic therapy
Topic

76. Medication Clean-up / Deprescribing 1/2
IF the medication is not effective or not indicated -> Stop the medication
Targets the correct condition
IF the medication is overprescribed -> Stop medication or decrease the dose
Don’t go cold turkey
IF the medication is potentially inappropriate -> Switch to a safer alternative
Discontinue all PRN medications that have not been used in >1 month

77. Medication Clean-up / Deprescribing 2/2
Discontinue, communicate with patient and other providers
Transition of care !!! Evaluate indication and use in post-acute setting
Achieve balance between over- and underprescribing
Less is more
What is the endpoint of therapy?
Failure in any one of these
Can result in adverse drug events (ADEs)
Topic

79. Take Home Messages Consider whether drug therapy is necessary
ADEs are common but can be minimized
Recognize BEERS/STOPP list medications
Assist patients with adherence
Prioritize therapeutic goals
Elicit patient values and preferences
Consider remaining life expectancy, quality of life, and functional status
Topic

80. “To do nothing is sometimes
a good remedy” (Hippocrates)
Thank you !!!